GSHDR - GROUP HEADER |
GSHDR | GS | Functional Group Header | ||
02 | GSHDR_GS02_APP_SNDR_CD | String | Application Senders Code | |
03 | GSHDR_GS03_APP_RCV_CD | String | Application Receivers Code | |
04 | GSHDR_GS04_D8 | Date/Time | Date | |
05 | GSHDR_GS05_TM | Time | Time | |
06 | GSHDR_GS06_GCN | Integer | Group Control Number |
STHDR - TRANSACTION SET HEADER |
STHDR | ST | Transaction Set Header | ||
02 | STHDR_ST02_TCN | String | Transaction Set Control Number | |
03 | STHDR_ST03_VERS_REL_IND_ID | String | Version, Release, or Industry Identifier |
STHDR | BHT | Beginning of Hierarchical Transaction | ||
01 | STHDR_BHT01_HIER_STRUC_CD | String | Hierarchical Structure Code | |
03 | STHDR_BHT03_REF_ID | String | Reference Identification | |
04 | STHDR_BHT04_TS_CRTN_D8 | Date/Time | Transaction Set Creation Date | |
05 | STHDR_BHT05_TS_CRTN_TM | Time | Transaction Set Creation Time |
L2000A - INFORMATION SOURCE LEVEL |
L2000A | HL | Information Source Level | ||
01 | L2000A_HL01_HIER_ID_NR | String | Hierarchical ID Number |
L2100A - PAYER NAME |
L2100A | NM1 | Payer Name | ||
03 | L2100A_NM103_PYR_NM | String | Payer Name | |
09 | L2100A_NM109_PAYR_ID | String | Payor Identification | |
09 | L2100A_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2000B - INFORMATION RECEIVER LEVEL |
L2000B | HL | Information Receiver Level | ||
01 | L2000B_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000B_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2100B - INFORMATION RECEIVER NAME |
L2100B | NM1 | Information Receiver Name | ||
02 | L2100B_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier | |
03 | L2100B_NM103_NFO_RCV_NM | String | Information Receiver Last or Organization Name | |
04 | L2100B_NM104_NFO_REC_FNM | String | Information Receiver First Name | |
05 | L2100B_NM105_NFO_REC_MNM | String | Information Receiver Middle Name | |
09 | L2100B_NM109_NFO_REC_ID_NR | String | Information Receiver Identification Number |
L2000C - SERVICE PROVIDER LEVEL |
L2000C | HL | Service Provider Level | ||
01 | L2000C_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000C_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2100C - PROVIDER NAME (Single Iteration) |
L2100C | NM1 | Provider Name | ||
02 | L2100C_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier | |
03 | L2100C_xx_NM103_PVR_LNM | String | Provider Last or Organization Name | |
04 | L2100C_xx_NM104_PVR_FNM | String | Provider First Name | |
05 | L2100C_xx_NM105_PVR_MNM | String | Provider Middle Name | |
07 | L2100C_xx_NM107_PVR_SFX | String | Provider Name Suffix | |
09 | L2100C_xx_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number | |
09 | L2100C_xx_NM109_SVC_PROV_NR | String | Service Provider Number | |
09 | L2100C_xx_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2000D - SUBSCRIBER LEVEL |
L2000D | HL | Subscriber Level | ||
01 | L2000D_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000D_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number | |
04 | L2000D_HL04_HL_CHLD_CD | String | Hierarchical Child Code |
L2000D | DMG | Subscriber Demographic Information | ||
02 | L2000D_DMG02_SBR_DOB_D8 | Date/Time | Subscriber Birth Date | |
03 | L2000D_DMG03_SUB_GENDR_CD | String | Subscriber Gender Code |
L2100D - SUBSCRIBER NAME |
L2100D | NM1 | Subscriber Name | ||
03 | L2100D_NM103_PERSN_LNM | String | Person Last Name | |
03 | L2100D_NM103_NONPSNENT_NM | String | Non-Person Entity Name | |
04 | L2100D_NM104_SBR_FNM | String | Subscriber First Name | |
05 | L2100D_NM105_SBR_MNM | String | Subscriber Middle Name or Initial | |
07 | L2100D_NM107_SBR_SFX | String | Subscriber Name Suffix | |
09 | L2100D_NM109_EMPLYR_ID | String | Employer?s Identification Number | |
09 | L2100D_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States | |
09 | L2100D_NM109_MEM_ID_NR | String | Member Identification Number |
L2200D - CLAIM STATUS TRACKING NUMBER |
L2200D | TRN | Claim Status Tracking Number | ||
02 | L2200D_TRN02_CUR_TRANS_TRAC_NR | String | Current Transaction Trace Number |
L2200D | REF | Payer Claim Control Number | ||
02 | L2200D_REF_PYR_CLM_NR | String | Payor?s Claim Number |
L2200D | REF | Institutional Bill Type Identification | ||
02 | L2200D_REF_BILL_TYP | String | Billing Type |
L2200D | REF | Application or Location System Identifier | ||
02 | L2200D_REF_LOC_NR | String | Location Number |
L2200D | REF | Group Number | ||
02 | L2200D_REF_GRP_NR | String | Group Number |
L2200D | REF | Patient Control Number | ||
02 | L2200D_REF_PATNT_ACCT_NR | String | Patient Account Number |
L2200D | REF | Pharmacy Prescription Number | ||
02 | L2200D_REF_PHRM_RX_NR | String | Pharmacy Prescription Number |
L2200D | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | ||
02 | L2200D_REF_CLM_NR | String | Claim Number |
L2200D | AMT | Claim Submitted Charges | ||
02 | L2200D_AMT02_TOT_SUB_CHGS | Date Timestamp | Total Submitted Charges |
L2200D | DTP | Claim Service Date | ||
03 | L2200D_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2200D_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2200D_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2210D - SERVICE LINE INFORMATION |
L2210D | SVC | Service Line Information | ||
01 | 02 | L2210D_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2210D_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2210D_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2210D_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2210D_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service |
01 | 02 | L2210D_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2210D_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 |
01 | 02 | L2210D_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2210D_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2210D_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2210D_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2210D_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | L2210D_SVC02_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount | |
04 | L2210D_SVC04_REV_CD | String | Revenue Code | |
07 | L2210D_SVC07_UN_SVC_CT | Decimal | Units of Service Count |
L2210D | REF | Service Line Item Identification | ||
02 | L2210D_REF_LIN_ITM | String | Line Item Control Number |
L2210D | DTP | Service Line Date | ||
03 | L2210D_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2210D_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2210D_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2000E - DEPENDENT LEVEL |
L2000E | HL | Dependent Level | ||
01 | L2000E_HL01_HIER_ID_NR | String | Hierarchical ID Number | |
02 | L2000E_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2000E | DMG | Dependent Demographic Information | ||
02 | L2000E_DMG02_PT_DOB_D8 | Date/Time | Patient Birth Date | |
03 | L2000E_DMG03_PAT_GNDR_CD | String | Patient Gender Code |
L2100E - DEPENDENT NAME |
L2100E | NM1 | Dependent Name | ||
03 | L2100E_NM103_PT_LNM | String | Patient Last Name | |
04 | L2100E_NM104_PT_FNM | String | Patient First Name | |
05 | L2100E_NM105_PT_MNM | String | Patient Middle Name or Initial | |
07 | L2100E_NM107_PT_SFX | String | Patient Name Suffix |
L2200E - CLAIM STATUS TRACKING NUMBER |
L2200E | TRN | Claim Status Tracking Number | ||
02 | L2200E_TRN02_CUR_TRANS_TRAC_NR | String | Current Transaction Trace Number |
L2200E | REF | Payer Claim Control Number | ||
02 | L2200E_REF_PYR_CLM_NR | String | Payor?s Claim Number |
L2200E | REF | Institutional Bill Type Identification | ||
02 | L2200E_REF_BILL_TYP | String | Billing Type |
L2200E | REF | Application or Location System Identifier | ||
02 | L2200E_REF_LOC_NR | String | Location Number |
L2200E | REF | Group Number | ||
02 | L2200E_REF_GRP_NR | String | Group Number |
L2200E | REF | Patient Control Number | ||
02 | L2200E_REF_PATNT_ACCT_NR | String | Patient Account Number |
L2200E | REF | Pharmacy Prescription Number | ||
02 | L2200E_REF_PHRM_RX_NR | String | Pharmacy Prescription Number |
L2200E | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | ||
02 | L2200E_REF_CLM_NR | String | Claim Number |
L2200E | AMT | Claim Submitted Charges | ||
02 | L2200E_AMT02_TOT_SUB_CHGS | Date Timestamp | Total Submitted Charges |
L2200E | DTP | Claim Service Date | ||
03 | L2200E_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2200E_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2200E_DTP_SVC_RD8_2 | End Date | Service (D8) |
L2210E - SERVICE LINE INFORMATION |
L2210E | SVC | Service Line Information | ||
01 | 02 | L2210E_SVC0102_ADA_CD | String | American Dental Association Codes |
01 | 02 | L2210E_SVC0102_JS_PRC_SPY_CD | String | Jurisdiction Specific Procedure and Supply Codes |
01 | 02 | L2210E_SVC0102_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
01 | 02 | L2210E_SVC0102_HIPPA_SNF_RT_CD | String | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code |
01 | 02 | L2210E_SVC0102_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service |
01 | 02 | L2210E_SVC0102_NDC542 | String | National Drug Code in 5-4-2 Format |
01 | 02 | L2210E_SVC0102_NUBC_UB92_CD | String | National Uniform Billing Committee (NUBC) UB92 |
01 | 02 | L2210E_SVC0102_ABC_CD | String | Advanced Billing Concepts (ABC) Codes |
01 | 03 | L2210E_SVC0103_PROC_MOD | String | Procedure Modifier |
01 | 04 | L2210E_SVC0104_PROC_MOD | String | Procedure Modifier |
01 | 05 | L2210E_SVC0105_PROC_MOD | String | Procedure Modifier |
01 | 06 | L2210E_SVC0106_PROC_MOD | String | Procedure Modifier |
02 | L2210E_SVC02_LIN_ITM_CHG_AMT | Decimal | Line Item Charge Amount | |
04 | L2210E_SVC04_REV_CD | String | Revenue Code | |
07 | L2210E_SVC07_UN_SVC_CT | Decimal | Units of Service Count |
L2210E | REF | Service Line Item Identification | ||
02 | L2210E_REF_LIN_ITM | String | Line Item Control Number |
L2210E | DTP | Service Line Date | ||
03 | L2210E_DTP_SVC_D8 | Start Date | Service (D8) | |
03 | L2210E_DTP_SVC_RD8_1 | Start Date | Service (D8) | |
03 | L2210E_DTP_SVC_RD8_2 | End Date | Service (D8) |
STHDR | SE | Transaction Set Trailer | ||
01 | STHDR_SE01_TS_SEG_CT | Integer | Transaction Segment Count | |
02 | STHDR_SE02_TCN | String | Transaction Set Control Number |
GSHDR | GE | Functional Group Trailer | ||
01 | GSHDR_GE01_NR_TS_INCLUDED | Integer | Number of Transaction Sets Included | |
02 | GSHDR_GE02_GCN | Integer | Group Control Number |